Abstract Introduction Breast cancer is common in women and its metastases involve the skin in approximately one quarter of patients. Accordingly, metastatic breast cancer shown to be cutaneous through histology must be distinguished from a wide variety of other neoplasms as well as the diverse morphologic variants of breast cancer itself. Case presentation We report the case of a 61-year-old Caucasian woman with cutaneous metastases of a bilateral ductal breast carcinoma that in histopathological examination mimicked an adnexal neoplasm with sebaceous differentiation. Conclusion Against the background of metastatic breast carcinoma, dermatopathological considerations of sebaceous differentiation of skin lesions are presented and discussed focusing on the rare differential diagnosis of sebaceous carcinoma of the breast.</p

A Al Zouman

A Fernandez-Flores

A Murakami

A Sanki

AG Marneros

CI Hood

Claudia Pfoehler

CM Dobson

Cornelia SL Müller

D Torchia

DA Ostler

EM Baum

Erich F Solomayer

F Petersson

Ferenc Z Takacs

GF Kao

JH Lin

K Bassioukas

KB Conner

LJ van Bogaert

M Hisaoka

MR Hussein

N Haas

RA Schwartz

Rebecca Körner

Thomas Vogt

English

PubMed

Crossref

Journal of Medical Case Reports

Metastatic breast carcinoma mimicking a sebaceous gland neoplasm: a case report

Springer - Publisher Connector

JOURNAL OF MEDICAL
CASE REPORTS
Metastatic breast carcinoma mimicking a
sebaceous gland neoplasm: a case report
Müller et al.
Müller et al. Journal of Medical Case Reports 2011, 5:428
http://www.jmedicalcasereports.com/content/5/1/428 (2 September 2011)
CASE REPORT Open Access
Metastatic breast carcinoma mimicking a
sebaceous gland neoplasm: a case report
Cornelia SL Müller1*, Rebecca Körner1, Ferenc Z Takacs2, Erich F Solomayer2, Thomas Vogt1 and Claudia Pfoehler1
Abstract
Introduction: Breast cancer is common in women and its metastases involve the skin in approximately one
quarter of patients. Accordingly, metastatic breast cancer shown to be cutaneous through histology must be
distinguished from a wide variety of other neoplasms as well as the diverse morphologic variants of breast cancer
itself.
Case presentation: We report the case of a 61-year-old Caucasian woman with cutaneous metastases of a
bilateral ductal breast carcinoma that in histopathological examination mimicked an adnexal neoplasm with
sebaceous differentiation.
Conclusion: Against the background of metastatic breast carcinoma, dermatopathological considerations of
sebaceous differentiation of skin lesions are presented and discussed focusing on the rare differential diagnosis of
sebaceous carcinoma of the breast.
Introduction
Skin metastases of malignant tumors arise principally
when the diagnosis of the primary cancer has been pre-
viously established, and cutaneous metastases from inter-
nal malignancies are an infrequent, although not totally
rare, phenomenon [1]. In contrast, breast cancer is very
common in women and its metastases frequently involve
skin, with cutaneous findings in about one quarter of
breast cancer patients [2].
Cutaneous metastases of carcinomas are encountered in
0.7-9.0% of all patients with cancer in general [3]. In the
main, skin metastases occur long after the diagnosis of
cancer, however, in some cases they may be the first sign
of clinically silent visceral malignancies. The location of
skin metastases depends on the location of the primary
malignancy, the mechanism of the metastatic spread, and
the gender of the patient. Cutaneous metastases can vary
in size and clinical appearance dependent upon the type of
primary malignancy. Some skin metastases may mimic
benign dermatological conditions such as cutaneous cysts,
hemangiomata, herpes zoster eruptions, alopecic patches,
and erysipelas [3].
In 2010 Fernandez-Flores investigated 78 cutaneous
biopsies from 69 patients and identified six histological
patterns of cutaneous metastasis: nodular, diffuse, infiltra-
tive, intravascular, bottom heavy, and top heavy [1]. The
majority of the patients were between 60 and 80 years of
age. The most frequent anatomical location of the metas-
tases was the abdomen. As to the primary tumor, breast
carcinoma was the most common in females. In 18% the
origin of the primary tumor was unknown and in all the
cases investigated there had been no clinical suspicion of
metastasis [1].
In breast carcinoma in particular there is a wide range of
clinical presentation of skin metastases. Most metastases
are observed on the chest wall; less common sites include
scalp, neck, upper extremities, abdomen and back [3]. In
general, eight specific clinical patterns associated with
cutaneous breast cancer are known: cancer en cuirasse [4],
inflammatory metastatic carcinoma (carcinoma erysipela-
todes) [2,5], carcinoma teleangiectaticum [4,6], alopecia
neoplastica [7,8], Paget’s disease [9,10], breast carcinoma
of the inframammary crease [11], metastatic mammary
carcinoma of the eyelid with histiocytoid histology [12],
nodular metastases [13,14], and mucinous adenocarci-
noma metastatic to the skin [2]. Skin metastases from
breast carcinoma can also be present in a zosteriform dis-
tribution when occurring at the sides of the abdomen
* Correspondence: cornelia.mueller@uks.eu
1Department of Dermatology, Saarland University Hospital, 66421 Homburg/
Saar, Germany
Full list of author information is available at the end of the article
Müller et al. Journal of Medical Case Reports 2011, 5:428
http://www.jmedicalcasereports.com/content/5/1/428 JOURNAL OF MEDICAL
CASE REPORTS
© 2011 Müller et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
[13,15]. Metastatic nodules are primarily caused by hema-
togenous spread, whereas inflammatory carcinomas and
carcinoma en cuirasse are caused by lymphatic spread [7].
In a case of cancer en cuirasse the fibrotic response is
induced by the invading cancer with infiltrating tumor
cells that resemble single files [2]. This leads to the forma-
tion of a chest wall that resembles a metal breastplate of a
cuirassier (a mounted cavalry soldier) [2,4]. In a case of
Paget’s disease, tumor cells infiltrate the epidermis directly
with a typical pagetoid spreading [7,16]. Alopecia neoplas-
tica presents as oval plaques or patches on the scalp that
may be confused clinically with alopecia areata [7,16].
Breast carcinoma metastases of the scalp usually manifest
as cutaneous nodules, although they also manifest less
commonly as alopecia neoplastica.
Tracking the differentiation from primary cutaneous
malignancies can be challenging due to the ability of the
tumor cells to mimic specific dermal structures. Although
most skin metastases show morphologic and immunohis-
tologic features of the primary malignancy, they can also
mimic other dermatological patterns on histology.
Case presentation
The initial dermatologic consultation of our 61-year-old
Caucasian female patient occurred two years ago when
she presented with a reddish, indolent nodule of the scalp
5 mm in diameter with local alopecia that she had noticed
for the first time four months before. A small punch
biopsy of her scalp exhibited solid proliferations of mono-
morphous tumor cells with a cytoplasm rich in vacuoles
and sebaceous differentiation. Subepidermal spreading of
the cells was knobby; a sclerodermiform-like spreading
was predominant within the reticular dermis. The cells
expressed pancytokeratin (MNF116) and epithelial mem-
brane antigen (EMA) but staining for BerEP4 and carcino
embryonal antigen (CEA) was negative. Therefore, we
initially established the diagnosis of a primary cutaneous
carcinoma with sebaceous differentiation. Upon thorough
review of our patient’s personal history she informed us of
a previous diagnosis of a poorly differentiated invasive
solid ductal breast carcinoma of her left breast five years
previously, which was positive for estrogen receptor (ER)
and progesterone receptor (PR), but negative for human
epidermal growth factor receptor 2 (HER-2/neu) (Figure 1,
right). At that time, our patient underwent ablatio mam-
mae left sided with ipsilateral dissection of the axillary
lymph nodes (18 out of 19 lymph nodes being positive)
and contralateral plastic surgery reduction of the right
breast, followed by radiochemotherapy with paclitaxel.
Regular follow-up over five years showed no clinical or
mammographic recurrence of the disease.
Further examination of our patient was then initiated. It
showed a second moderately differentiated invasive ductal
breast carcinoma of her right breast with a sonographic
tumor thickness of 5 mm (Figure 1, left). Computed chest
tomography revealed multiple pulmonary and lymphatic
metastatic lesions within the ipsilateral axillary lymph
nodes. This ductal breast carcinoma was positive for ER
and PR. Ki67 expression demonstrated that 20% of the
tumor cells were proliferating. No overexpression of HER-
2/neu was observed.
The tumor of the scalp was surgically removed in our
department. Histopathological examination of this tissue
showed a solid tumor consisting of large monomorphous
cell proliferations with sebaceous differentiation, similar to
the features found in the previous biopsy (Figure 2a, b).
The immunophenotype was identical. Additionally, the
cutaneous tumor cells were positive for ER and PR, with
no evident overexpression of HER-2/neu (Figure 3). More-
over we performed an adipophilin stain that was negative
in the tumor cell fraction. Sebaceous glands expressing
adipophilin served as internal control (Figure 2c).
Figure 1 Imaging of both breast tumors. Left: Mammographic examination of her right breast revealed a 6 mm dense structure behind her
nipple. Right: Longitudinal and transverse scan planes of a lesion. In the upper outer quadrant of her left breast, at two o’clock, approximately 3
cm from the nipple is an irregular shaped mass with hypoechoic texture and with hyperechogenic blurred margins, measuring 19.4 × 19 × 19.5
mm, which disturbs and infiltrates the architecture of the surrounding normal breast tissue, ACR-BIRADS 5.
Müller et al. Journal of Medical Case Reports 2011, 5:428
http://www.jmedicalcasereports.com/content/5/1/428
Page 2 of 5
Our patient received axillary right sentinel node
biopsy, ablatio mammae right, and one cycle of che-
motherapy with paclitaxel and bevacizumab, but died
due to sepsis two months after the diagnosis of cuta-
neous metastatic breast carcinoma. Detailed clinical data
are given in table 1.
We were able to establish the final diagnosis of meta-
static breast cancer with the histologic appearance of a
sebaceous differentiated primary cutaneous carcinoma.
Our patient had bilateral ductal breast cancer with identi-
cal hormone receptor status within five years. It remains
unclear whether the cutaneous metastasis originated
from the initially diagnosed breast cancer of her left
mammary or from the second ductal carcinoma of her
right breast.
Discussion
Cutaneous metastatic breast cancer must be distin-
guished from a wide variety of other neoplasms using his-
tology. In the case presented, the tumor cells imitated the
histological and immunohistological pattern of a sebac-
eous gland neoplasm.
Interestingly, sebaceous differentiation can also occur in
variable morphologic types of breast carcinoma, such as
infiltrating or invasive ductal carcinoma, adenoid cystic
carcinoma as well as others [17]. It was therefore critical
to determine whether the breast carcinoma of our patient
showed any differentiation towards sebaceous carcinoma
of the breast within a ductal mammary carcinoma. In this
setting, a dermatopathologist must also bear in mind the
Figure 2 Excisional specimen from the scalp. a-b: Hematoxylin
and eosin stained slide. Solid tumor consisting of large
monomorphous cell proliferations with sebaceous differentiation. c:
Staining with monoclonal antibody against adipophilin reveals
negativity of the tumor cells while sebaceous glands express
adipophilin strongly.
Figure 3 Main immunohistochemical features of the tumor.
Immunohistochemistry with (a) PR and (b) ER being strongly
expressed within the tumor cells.
Müller et al. Journal of Medical Case Reports 2011, 5:428
http://www.jmedicalcasereports.com/content/5/1/428
Page 3 of 5
differential diagnosis of an underlying metastasizing carci-
noma of the breast with sebaceous differentiation (synon-
ymous with sebaceous carcinoma of the breast) [17].
The first description of a mammary sebaceous carci-
noma was made in 1977 as a variant of lipid-rich carci-
noma of the mammary gland [18]. The immunoreactivity
is similar to other previously described sebaceous carcino-
mas (cytokeratin, EMA and CEA). Contradictory opinions
exist concerning the immunohistochemistry for the andro-
gen receptor, ER and PR [19]. Additionally, controversy
remains as to whether sebaceous carcinoma of the breast
is a distinct entity or a variant of lipid-rich carcinoma of
the breast [19]. Hence, little is known about the prognosis
of sebaceous carcinoma of the breast in general [19].
Regardless of this histogenetic discussion, dermato-
pathologists must be aware of this opportunity for mis-
diagnosis of diverse sebaceous neoplasms of the skin.
Histological mimicry can hamper the correct diagnosis in
small biopsy specimens because the lesions cannot be
evaluated as whole, dimensional structures. Therefore, sus-
picious lesions should be excised completely. Reactivity for
adipophilin is of great advantage in this setting [20]. Adi-
pophilin was recently shown to be expressed in sebocytes
and sebaceous lesions and can be valuable in an immuno-
histochemical panel when evaluating cutaneous lesions
with clear cell histology in order to differentiate true
sebaceous origin from its epigones, as in this case.
Conclusion
Clinically, our patient presented with a reddish nodule on
her scalp that caused focal alopecia, which was misdiag-
nosed in the first biopsy specimen as primary carcinoma
of the skin with sebaceous differentiation. Due to the
uncommon differentiation of the cells and the sebaceous-
like pattern, diagnosis of cutaneous metastasis of a breast
carcinoma was hard to establish on the biopsy. Only after
complete removal of the lesion and with knowledge of
the whole history of our patient could we finally establish
the diagnosis of metastatic breast cancer.
Consent
Written informed consent for publication from the
patient’s next of kin could not be obtained despite all
reasonable attempts. The case is important to public
health and every effort has been made to protect the
identity of our patient. There is no reason to believe
that our patient would object to publication.
Author details
1Department of Dermatology, Saarland University Hospital, 66421 Homburg/
Saar, Germany. 2Department of Obstetrics and Gynecology, Saarland
University Hospital, 66421 Homburg/Saar, Germany.
Authors’ contributions
CSLM did all the histological reports, performed the histological examination
and was a major contributor in writing the manuscript. RK collected the
patient’s data and wrote parts of the manuscript. ZFT and EFS cared for the
patient in the gynecology department and provided the images of the
breast. TV approved the final manuscript. CP cared for the patient in the
dermatology outpatient unit. All authors have read and approved the final
manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 28 March 2011 Accepted: 2 September 2011
Published: 2 September 2011
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Table 1 Synopsis of disease
Date Diagnosis Therapy Staging
Five years prior
to presentation
Poorly differentiated invasive solid ductal breast carcinoma of the left
breast.
G2-3,
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PR positive (70%);
HER-2/neu negative
Ablatio mammae left.
Axillary lymph node
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No organ metastasis
At presentation Metastatic breast cancer of the scalp with the histologic appearance of a
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ER and PR positive;
HER-2/neu negative;
EMA positive;
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adipophilin negative
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after
presentation
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G2,
ER positive (30%);
PR positive (> 90%);
HER-2/neu negative
Ablatio mammae right with
sentinel node biopsy right.
Chemotherapy with
paclitaxel and bevacizumab.
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http://www.jmedicalcasereports.com/content/5/1/428
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doi:10.1186/1752-1947-5-428
Cite this article as: Müller et al.: Metastatic breast carcinoma mimicking
a sebaceous gland neoplasm: a case report. Journal of Medical Case
Reports 2011 5:428.
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Abstract Introduction Breast cancer is common in women and its metastases involve the skin in approximately one quarter of patients. Accordingly, metastatic breast cancer shown to be cutaneous through histology must be distinguished from a wide variety of other neoplasms as well as the diverse morphologic variants of breast cancer itself. Case presentation We report the case of a 61-year-old Caucasian woman with cutaneous metastases of a bilateral ductal breast carcinoma that in histopathological examination mimicked an adnexal neoplasm with sebaceous differentiation. Conclusion Against the background of metastatic breast carcinoma, dermatopathological considerations of sebaceous differentiation of skin lesions are presented and discussed focusing on the rare differential diagnosis of sebaceous carcinoma of the breast.</p

Solomayer Erich F

Takacs Ferenc Z

Körner Rebecca

Müller Cornelia SL

Vogt Thomas

Pfoehler Claudia

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Metastatic breast carcinoma mimicking a sebaceous gland neoplasm: a case report

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